PHINMA UNIVERSITY OF ILOILO

COLLEGE OF ALLIED HEALTH SCIENCES

Nursing Department

NURSING CARE PLAN

NURSING
ASSESSMENT NURSING DIAGNOSIS PLANNING RATIONALE EVALUATION
INTERVENTIONS
Short term goal: Independent Short term goal:
Subjective Data: Ineffective Airway After 4 hrs of nursing * Establish vapport * To gain trust After 4 hrs of nursing
“Nabudlayan ang bata ko clearance related to interventions, the * Monitor vitalsign * To know baseline status interventions,the goal
magginhawa" as increased production & patient will be able to * Encourage * To prevent situation that was met that the patient
verbalized by the mother retained pulmonary oppurtunities for rest and will aggrevate the
verbalize understanding able to verbalize
of the patient. secretions as evidenced limit physical activities conditions
causative factors that understanding causative
* Increased fluid intake * Hydration can help
by: allergerns like smoke, factors that allergerns
2,000ml/day prevent one accumulation
Objective Data: 1. RR:23cpm dust, fumes, feather like smoke, dust, fumes,
of riscous secretion
* V/S 2. Productive cough with pillows can contribute to * Assess the rate and feather pillows can
clearance
T: 36°C yellowish sticky phlegm ineffective airway depth of respiration contribute to ineffective
* To monitor rapid
PR: 64bpm 3. Labored breathing * Instruct patient to wear
clearance breating or shallow airway clearance
RR: 23 cpm 4. Nasal flaring is noted mask at all times to avoid
Long term goal: respiration Long term goal:
* Productive cough with causative factors * To avoid irritants that
After 8 hrs of nursing After 8 hrs of nursing
yellowish sticky phlegm * Elevate head of the bed can increased musuc
interventions, the interventions, the goal
and change position secretary production
*Labored breathing patient will demonstrate was partially met that
frequently which can interfere with
* Nasal flaring is noted behaviors to improve the patient demonstrate
Dependent: airway clearance
airway clearance * Assist in administering behaviors to improve
* Promotes expectoration
medication airway clearance as
cleansing or infection
* Assist for PAI treatment * To promote deeper evidenced by:
1. RR: 18cpm
Collaborative: respiration and cough 2. expectorate secretions
* Refer to dieticians * To ensure/ clear 3. unlabored breathing
having blenderized diet maintain open airway and 4. nasal flaring is noted
for the patient removal secretions
* Appropriate mixture of
food as well as balanced meal
provides nutrients need
PREPARED BY: ______________________________________